General Approach to All Patients

Cardiac Arrest General Approach

In the event a patient suffers cardiac arrest in the presence of EMS, the absolute highest priority is to apply the AED/Defibrillator and deliver a shock immediately if indicated. In the setting of cardiac arrest not witnessed by EMS, perform CPR immediately and continuously while setting up for rhythm analysis and delivery of shocks. If shockable rhythm present, deliver shock without delay.

Mechanical CPR devices can be used as the initial compression delivery mode only if there is no delay in applying the device. If a delay in applying the device occurs, begin manual compressions immediately.

Basic Life Support

  • Check responsiveness
  • Call “Patient Contact” time to dispatch
  • Open airway, check breathing, and feel for carotid pulse
  • If a pulse is not definitely felt within 10 seconds immediately begin chest compressions while preparing to apply AED or Monitor/Defibrillator
  • Assist ventilation with minimal interruptions chest compressions
    • 30:2 compression to ventilation ratio for BLS
    • EMT's are authorized to place Laryngeal Tube Airways (LTA)
  • Apply AED and follow directions
  • If shockable rhythm identified by AED:
    • Administer shock and call “first shock” time to dispatch
    • Resume CPR immediately after shock is delivered for 2 minutes
    • Do not wait for pulse or rhythm check
  • Re-analyze rhythm using AED and follow directions
  • Continue assisted ventilation without chest compressions if pulse present

Advanced Life Support

  • Advanced airway/ventilatory management
    • Ventilation rate of 8-10 per minute (avoid hyperventilation)
  • If unwitnessed arrest, immediately begin CPR and continue until ready for rhythm analysis
  • Follow algorithm for specific rhythm
  • Establish peripheral IV or Adult Intraosseous access
    • All medications listed for IV use can be given IO
    • Endotracheal delivery of Epinephrine, Naloxone, and Atropine is an acceptable last resort if peripheral IV or IO access cannot be achieved
      • When delivered via endotracheal tube, administer 2-2.5 times the IV dose diluted in 5-10 mL of 0.9% NS or sterile water

Important Principles for Cardiac Arrest Management

  • Minimize interruptions in chest compressions
    • Compressions should begin immediately upon identifying pulselessness
    • Compressions should be continuous (no pause for ventilations)
  • Minimize time between ceasing compressions and delivering shocks in VF/VT
    • Whenever possible, continue CPR while defibrillator is charging
  • Avoid hyperventilation (use rate of 8-10 breaths/minute)
  • Capnography is required on every patient with an ETT or LTA in place
    • Allows rapid assessment of ROSC (marked by a sudden increase in ETCO2 value)
  • Consider the H's and T's that may have caused the arrest
H's T's
Hypoxia Toxins
Hypovolemia Tamponade (Cardiac)
Hydrogen Ion (Acidosis) Tension pneumothorax
Hyperkalemia Thrombosis, pulmonary
Hypothermia Thrombosis, coronary

Cardiac Arrest Flowchart

Cardiac Arrest - Asystole

When asystole is seen on the cardiac monitor confirmation of the rhythm shall include a printed rhythm strip, as well as interpretation of the rhythm in more than one lead. Low amplitude V-Fib or PEA may be difficult to distinguish from asystole when using only the cardiac monitor display for interpretation.

Advanced Life Support

  • Follow Cardiac Arrest-General Approach protocol
  • Consider and treat possible causes:
Potential Cause of Asystole Treatment
Hypoxia Secure airway and ventilate
Hyperkalemia (end stage renal disease) Sodium Bicarbonate 1 mEq/kg IV/IO
Calcium chloride 1 gram IV/IO
Hypothermia Active rewarming
Toxins (drug overdose) See below
  • Epinephrine 1:10,000 1 mg IV/IO every 3-5 min during arrest
  • Drug overdoses (see specific drug OD/toxicology section)
    • Glucagon 5 mg IV/IO for calcium channel and B blocker OD
    • Calcium Chloride 1 gram IV/IO for calcium channel blocker OD
      • Avoid if patient on Digoxin / Lanoxin
    • Sodium Bicarbonate 1 mEq/kg IV/IO for Tricyclic antidepressant OD
    • Naloxone (Narcan) 2 mg IV
      • When narcotic overdose is likely repeat every 3-5 minutes (Maximum 8 mg)
      • May be given IM if no IV/IO available
  • If no response to resuscitative efforts in 20 minutes (at least 2 rounds of drugs) consider discontinuation of efforts (see “Termination of Resuscitation” protocol)

Cardiac Arrest - Pulseless Electrical Activity

Advanced Life Support

  • Follow Cardiac Arrest-General Approach protocol
  • Consider and treat possible causes:

    Potential Cause and Treatment of PEA Table

  • Epinephrine 1:10,000 1 mg IV/IO every 3-5 min during arrest
  • Drug overdoses (see specific drug OD/toxicology section)
    • Glucagon 5 mg IV/IO for calcium channel and B blocker OD
    • Calcium Chloride 1 gram IV/IO for calcium channel blocker OD
      • Avoid if patient on Digoxin / Lanoxin
    • Sodium Bicarbonate 1 mEq/kg IV/IO for Tricyclic antidepressant OD
    • Naloxone (Narcan) 2 mg IV/IO for possible narcotic OD
      • When narcotic overdose is likely repeat every 3-5 minutes (Maximum 8 mg)
      • May be given IM if no IV/IO available

Cardiac Arrest - Ventricular Fibrillation

Advanced Life Support

  • Follow Cardiac Arrest-General Approach protocol
  • Defibrillate for persistent VF/VT:
    • 200 J for initial biphasic shock, 360 J for subsequent shocks
    • Continue CPR immediately after shock (do not stop to check pulse or rhythm)
    • Call first defibrillation time to dispatch (if not done above)
  • Analyze rhythm after 2 minutes of good CPR; If VF/VT persists:
    • Defibrillate at 360 J
    • Continue CPR immediately after shock (do not stop to check pulse or rhythm)
    • Epinephrine 1:10,000 1 mg IV/IO every 3-5 min during arrest
  • Analyze rhythm after 2 minutes of good CPR; If VF/VT Persists:
    • Defibrillate at 360 J
    • Continue CPR immediately after shock (do not stop to check pulse or rhythm)
    • Amiodarone 300 mg IV/IO bolus
      • For persistent VF/VT give Amiodarone 150 mg IV/IO bolus on second round
  • Continue cycle of CPR & Drug→Rhythm Check→CPR→Shock→CPR and Drug→Rhythm Check→CPR→Shock as needed
  • For persistent VF without interuption despite at least 5 shocks at 360 J
    • If a second monitor/defibrillator is available, perform Double Sequential Defibrillation as described in the Orange County EMS System Procedure Manual
    • Continue CPR immediately after shock (do not stop to check pulse or rhythm)
    • Transport to the nearest Emergency Department
  • Additional interventions to consider in special circumstances:
    • Magnesium Sulfate 2 g IV/IO push over 1-2 minutes only if suspected Polymorphous VT (torsades de pointes) or hypomagnesemic state (chronic alcohol, diuretic use)
    • Sodium Bicarbonate 1 mEq/kg IV/IO if suspected hyperkalemia (e.g. dialysis patient) or tricyclic antidepressant OD

Cardiac Arrest - Post Resuscitation Care

Basic Life Support

  • Maintain assisted ventilation as needed
  • Supplemental 100% oxygen

Advanced Life Support

  • Full ALS Assessment and Treatment
    • Obtain a 12 lead ECG and initiate STEMI Alert if criteria exists
  • For hypotension (systolic BP < 90 mmHg) not improved by fluid boluses, or when fluid boluses are contraindicated
    • Dopamine infusion at 5-20 mcg/kg/min titrated to maintain systolic BP > 90 mm Hg
  • Administer supplemental oxygen with a target oxygen saturation of 94-98%
  • For patients with assisted ventilation, provide 10-12 breaths per minute with a target ETCO2 of 35-40 mmHg
  • Treat arrhythmias as directed by appropriate Cardiac Arrhythmias protocol
  • If cardiac arrest reoccurs refer to appropriate algorithm based on presenting rhythm:
    • Total cumulative dose of Amiodarone should not exceed 450 mg (300 mg + 150 mg)
  • If patient becomes combative, administer Midazolam (Versed) 2.5 mg slow IV or 5 mg IM
    • Repeat Midazolam (Versed) 2.5 mg slow IV or 5 mg IM if patient still combative
  • Transport to the nearest PCI (Percutaneous Coronary Intervention) capable hospital
    • PCI capable hospital campuses in and around Orange County:
      • Dr. P. Phillips Hospital
      • Florida Hospital Altamonte
      • Florida Hospital Orlando
      • Health Central Hospital
      • Orlando Regional Medical Center
      • Osceola Regional Medical Center
    • The following hospitals function as part of the Florida Hospital STEMI receiving network, and can arrange rapid interfacility transport of STEMI Alert patients when primary transport by EMS is not operationally feasible:
      • Florida Hospital (FH) Apopka, FH East, FH Kissimmee, and Florida Hospital Celebration Health

Cardiac Arrest - Termination of Resuscitation Medical

The paramedic has the discretion to continue resuscitation efforts in any case despite Termination of Resuscitation criteria being met if scene safety, location, patient’s age, time of arrest, or bystander input compels this decision.

When asystole is seen on the cardiac monitor confirmation of the rhythm shall include a printed rhythm strip, as well as interpretation of the rhythm in more than one lead. Low amplitude V-Fib or PEA may be difficult to distinguish from asystole when using only the cardiac monitor display for interpretation.

Medical Control Contact Not Required

The paramedic may terminate resuscitative efforts in nonhypothermic adults provided all 6 of the following criteria exist:

  • Initial rhythm is asystole confirmed in two leads and on printed rhythm strip
  • Terminal rhythm is asystole confirmed in two leads and on printed rhythm strip
  • Secure airway confirmed by digital capnography (ETT or LTA)
  • At least four doses of Epinephrine have been administered (given every 3-5 min)
  • Cardiac arrest refractory for at least 20 minutes of ACLS
  • Quantitative ETCO2 value is < 10 mmHg with effective CPR, after 20 minutes of ACLS

Do not terminate resuscitation if transport has been initiated

Medical Control Required

Medical Control contact for "termination of resuscitation" orders is appropriate if cardiac arrest persists after at least 20 minutes of aggressive ACLS. Provide the Medical Control Physician with the following information:

  • Initial rhythm and terminal rhythm
  • Method of airway management and vascular access
  • Medications given during the arrest
  • ETCO2 value
  • Total amount of time working the arrest

The decision to continue efforts and transport is at the sole discretion of the Medical Control Physician. If termination orders are given, document the time the order was given as the "time of death".

Do not terminate resuscitation if transport has been initiated

Cardiac Arrest - No Resuscitation Attempt

No resuscitation attempt is indicated for cardiac arrest in the following scenarios:

Obvious signs of death

  • Pulseless, apneic and no other signs of life present AND any of the following:
    • Rigor mortis
    • Decomposition of body tissues
    • Dependent lividity
    • Injuries incompatible with life (e.g. incineration, decapitation, hemicorporectomy)

Blunt or penetrating trauma (all criteria must be met)

  • Pulseless, apneic and no other signs of life present
  • Lack of pupillary reflexes and spontaneous movement
  • Asystole or agonal rhythm < 20 on cardiac monitor
  • Patients who become pulseless after severe traumatic injury when transport to the nearest ED cannot be accomplished within 15 minutes (i.e. prolonged extrications) provided that all other signs of life are absent and transport has not been initiated

"Do Not Resuscitate" (DNR Order)

  • When presented with a State of Florida DO NOT RESUSCITATE order (Form 1896)
    • Must be on YELLOW Paper and signed by the patient's physician

Use caution in the following scenarios:

  • When mechanism of injury is inconsistent with traumatic cardiac arrest
  • Lightning or other high voltage electrical injuries
  • Drowning
  • Suspected hypothermia

In order to preserve trace evidence at a death scene, avoid covering the body when it is prudent and reasonable to do so. In the scenario when a person is deceased at a residence or other private area, partition off, or otherwise restrict access to, the area where the body is as opposed to covering the body. Law Enforcement Officers on the scene should be involved in the decision to how best respect the patients dignity without compromising investigative needs.

There is no strict contraindication on covering the deceased, especially when the crews are trying to protect the dignity of the deceased or the mental state of their family.